BENZODIAZEPINE DISCONTINUATION: SHARED MEDICAL APPOINTMENTS FOR - - PowerPoint PPT Presentation

AN INTEGRATED APPROACH TO BENZODIAZEPINE DISCONTINUATION:

SHARED MEDICAL APPOINTMENTS FOR VETERANS CO-PRESCRIBED OPIOIDS AND BENZODIAZEPINES

Elizabeth (Betsy) Crowe, PhD Lucille J. Carriere, PhD

Objectives

 Review current relevance to Veteran healthcare  Explain the importance of interdisciplinary efforts in

benzodiazepine discontinuation

 Describe the Opioid/Benzodiazepine SMA  Discuss conclusions and lessons learned

Opioid + Benzodiazepine Use in Veterans

Park TW et al. BMJ. 2015

422,786 Veterans

• n Opioids

27% on also on Benzo 2,400 Fatal ODs Benzo prescribed in ~50% of fatal ODs

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.

• BMJ. 2015.

Benzodiazepine Discontinuation

Why Discontinue Benzos?

 No long-term indication  Safety Concerns

 Falls  Hip fractures  Sedation

 Psychological concerns

 Cognitive impairment  Dependence  Barrier to psychotherapeutic progress

Benzodiazepine Discontinuation

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“Providing individuals with advice to cease benzodiazepine use or with a more extensive intervention increases cessation rates significantly in comparison with routine care.”

Parr et al. 2008.

 Gradual tapering alone has limited effectiveness

 50-60% of users resume medication

Role of Psychology

Role of Psychology

 Effective benzodiazepine discontinuation must

include:

Otto et al., 2002

Decrease conditioned fears of somatic sensations Provide patients with coping skills for managing anxiety Provide patients with skills for minimizing withdrawal symptoms

Role of Psychology

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 General psychology skills  Values and goals identification  Motivational Interviewing

Role of Psychology

 Taper + CBT = Best Discontinuation Results (Morin et al.,

2004; Baillargeon et al., 2003)

 Taper + CBT = More successful dose reduction than

taper alone (Voshaar et al., 2003)

Shared Medical Appointment

SMA

12

Target Population

Veterans prescribed chronic

• pioid and

benzodiazepine therapy

Clinical Structure

6 shared medical appointment (SMA) sessions 90 minute SMA (60 min group content, 30 min individual check-in) Individual sessions

• ffered for patients

not appropriate for group setting

Group Facilitators

Psychology Post- Doctoral Fellow PGY-2 Psychiatric Pharmacy Resident

Group Supervisors

1 Mental Health Clinical Pharmacy Specialist 2 Licensed Clinical Psychologists

SMA Content

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Risk Education / Naloxone Distribution Psychoeducation Cognitive Reappraisals Relaxation Strategies / Mindfulness Techniques Insomnia Management Strategies Non-benzo Pharmacotherapy Options Non-Pharm Pain Management Strategies PTSD and Benzodiazepines Individualized Taper Recommendations

SMA Results

Results: Interim Data

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Baseline Characteristics (N = 11) Average ± Standard Deviation (Range) Male Gender 91% Age (years) 64 ± 8.6 (50 – 74) Race (Caucasian) 91% High Risk Comorbidity (N=11) Percentage (n=number

• f patients)

PTSD 45.5% (n=5) Chronic Respiratory Disease 36.4% (n=4) Sleep Apnea 45.5%(n=5) Elderly (>65 years) 54.5% (n=6) Dementia 9.1% (n=1) RIOSORD Score 48 ± 10.96 (34 – 65)

Results: Interim Data

Primary Psychiatric Diagnoses Percentage (n = number of patients) PTSD 27.3% (n=3) Other specified trauma - and stressor-related disorder 9.1% (n=1) General Anxiety Disorder 9.1% (n=1) Unspecified Anxiety Disorder 36.4% (n=4) Major Depressive Disorder 18.2% (n=2)

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Baseline Assessment Scores Average ± Standard Deviation PHQ-9 9.7 ± 6.18 GAD-7 6.33 ± 6.03 PCL-5 22.62 ± 16.46 AUDIT-C 1 ± 1.63 ISI 12.9 ± 5.73 DAST-10 1 ± 0.41

Results: Interim Data

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5 10 15 20 25 30 35 Baseline Current Diazepam Dose Equivalents (mg)

Benzodiazepine Taper Progress

Patients who have completed/currently enrolled in SMA

A (Fall16) B (Fall16) D (Spring17) E (Spring17) F (Spring17)

Lessons Learned

Lessons Learned: Interprofessional Competencies

Roles & Responsibilities

Mutual dependence Recognize

• ne’s

limitations

Interprofessional Communication

Responsive and responsible Consensus

• n ethical

principles

Lessons Learned: SMA Content

Cognitive component: Taper-specific Patient understanding: Repetition is key!

Lessons Learned: System-Level

Interprofessional emphasis of facility Provider buy-in Add psychiatry to SMA team Various Modalities: Individual SMAs, CVT

Acknowledgements

 Lucille J. Carriere, Ph.D.  Caitlin Dirvonas, Pharm.D., BCPS, PGY-2 Psychiatric

Pharmacy Resident

 Scott Fernelius, Ph.D., Psychology Postdoctoral

Fellow

 Ashley Barroquillo, Psy.D., Licensed Clinical

Psychology

 Jennifer Bean, Pharm.D., BCPS, BCPP